The risk of DDH between breech and cephalic-delivered neonates using Graf ultrasonography.

PURPOSE: Developmental dysplasia of the hip (DDH) is one of the most common musculoskeletal disorder in infants. The most significant risk factors include female gender, breech presentation, left hip and family history. In this study, we utilized the Graf method at different time intervals to evaluate both breech-delivered and cephalic-born newborns. The objectives were to compare the incidence of DDH in cephalic and breech-delivered neonates and investigate whether the hip joints of neonates delivered in the breech position exhibit a distinct maturation pattern. MATERIAL AND METHODS: We studied prospectively 618 hip joints (309 newborns). Each hip joint was examined with the Graf method in four time periods as follows: Phase #1 (0-1 weeks), Phase #2 (1-4 weeks), Phase #3 (4-7 weeks), and Phase #4 (7-10 weeks). The α and ß angles for each hip joint were measured, and the hips were classified according to Graf classification. With our statistical analysis within the different phases, we were able to investigate potential variations in the maturation patterns between newborns delivered in the breech and cephalic delivery positions. RESULTS: A significant difference (at the 5% level) was observed in Phase 1 between breech and cephalic-delivered neonates (35.6-8.6%). This difference tended to decrease in next phases (13.6-1% in Phase 2, 2.5-0% in Phase 3 and 1.7-0% in Phase 4). A significant difference (at the 5% level) for cephalic-delivered neonates was also observed between Phase 1 and Phase 4 (8.5-0%), but the percentages were low. Additionally, the breech-delivered had extreme difference in incidence of DDH from Phase 1 to Phase 4 (35.6-11.9%, 2.5%, and 1.7%, respectively). CONCLUSION: It appears that there is an actual difference in the incidence of DDH between breech-delivered and cephalic-delivered neonates, although the difference may be less significant than previously considered. The majority of the breech-delivered neonates that were initially considered as pathological (Phase 1) are, in fact, healthy. This is ascertained in subsequent ultrasound examinations conducted in later phases (Phases 2-4), when the incidence of pathological cases decreases. This could be attributed to potential different maturation pattern between these groups.

Ultrasonographic screening for developmental dysplasia of the hip: the Graf method revisited.

Until the 1980s, the diagnosis of developmental dysplasia of the hip (DDH) was based on clinical examination and radiographic imaging. In 1980, Reinhard Graf developed his own ultrasonographic method for the examination of the infant hip joint. Graf's method evaluates the osseous and cartilaginous coverage of the femoral head by the acetabulum in the infantile hip joint by measuring the angles α and ß. The validity of Graf method is that with these measurements the hip joint is further classified by Graf classification into types I to IV that guide treatment. Currently, Graf method is considered the gold standard examination for the diagnosis of DDH in many European countries. This review article aims to discuss the incidence, risk factors and pathophysiology of DDH, and to emphasize on the Graf method for the evaluation, classification, prevention and further management of this entity.

Developmental Dysplasia of the Hip: A Review.

Developmental dysplasia of the hip (DDH) is the most common musculoskeletal disorder of the infant age. Its incidence ranges from 0.06/1000 to 76.1/1000 live births and is more frequent in female infants. Breech position, family history and firstborn children are the main risk factors for DDH and this disorder is also associated with the presence of other congenital deformities. Anatomically, the acetabulum remains shallow and the femoral head grows in a wrong position. Clinical examination is important and tests such us Barlow and Ortolani give indications only for a part of the spectrum of this entity. Nowadays the sonographic examination is the most accurate option for the diagnosis. Graf classification categorizes the DDH cases in four types, from normal to dislocated hip, by description and measuring specific angles in sonographic examination. The wide usage of ultrasonography has decreased the non-diagnosed or neglected cases; treatment begins immediately in young age and is usually conservative with the usage of devices such as Pavlik harness and hip spica. To enhance the literature, we searched for published studies on DDH, to summarize the pathogenesis and the diagnosis and to discuss the treatment and outcome of the patients with this disorder.

International Interdisciplinary Consensus Meeting on the Evaluation of Developmental Dysplasia of the Hip.

In September 2018, an international meeting of doctors of various disciplines, with expertise in the detection and treatment of DDH, was held in Csolyospalos, Hungary. The aim was to achieve consensus on the detection and early treatment of the condition and to develop a standardized system of teaching and training for hip ultrasound. There was strong agreement that US screening is essential. Specifically the Graf technique was selected as the technique of choice. Universal US screening was strongly favored. Screening should be carried out as soon as possible, but not later than the sixth week of age. US screening is cost-effective, does not result in overtreatment, and contributes to a reduction of long-term consequences. The essential principle of treatment is timely application of a device to achieve reduction, retention and maturation, by holding the hips in flexion, and a safe degree of abduction. It was agreed that the effectiveness of any screening policy depends on the correct scanning technique. Therefore, standardization of teaching and training of the Graf technique is mandatory. A unified teaching policy and materials should be developed for this purpose. Certification, re-certification and audit were discussed. The group, which has been formalized as the International Interdisciplinary Consensus Committee On DDH Evaluation (ICODE), will continue to meet and work towards establishing international consensus on DDH, standardizing and developing teaching and training of the Graf technique for hip US, and maintaining standards for detection and management.

Ultrasonographic diagnosis of carpal tunnel syndrome: introducing a new approach.

INTRODUCTION: CTS, the most common nerve entrapment syndrome of the upper limb, is being diagnosed by clinical criteria, in most cases supported by the electrodiagnosis method, which appears limits regarding its sensitivity and specificity and suggests an intervening and expensive technique. The purpose of this study was to contribute to establishing U/S examination as a method with at least of the same accuracy with electrodiagnosis. MATERIAL AND METHOD: A sample of 60 healthy individuals and 30 patients suffering from CTS was scanned. The diagnosis was conducted by both clinical and electrodiagnostic criteria, or by clinical criteria supported by postsurgical outcome. METHOD: In order to improve the accuracy of measurements, the anteroposterior to transverse diameter of the median nerve inside the canal and in its entrance was scanned and compared, by sonography. The examination conducted three times for each dimension, and the mean value per individual was calculated. RESULTS: The mean ratios for the 60 healthy wrists was found to range within the interval 0.49-0.88 (presenting a mean value of 0.66), and the corresponding for the 30 suffering from CTS wrists was within the interval 1.12-1.59 (with a mean value of 1.39). CONCLUSION: The statistical analysis of the examination results clearly demonstrates that the interval of ratios over the value 1.07 can be considered completely safe to diagnose that someone is suffering from CTS. In correspondence, a U/S measurement of ratios in the area up to 0.79 is completely safe to opine that this wrist refers to a healthy individual. The intermediate range of ratios 0.79-1.0 suggests a grey zone, which, by the rational of this study, does not include discrete CTS or healthy cases. This "gap" may describe subclinical or mild cases of CTS which were not been taken under consideration and for which there is no rational to interfere surgically. In the everyday's practice clinical point of view, the grey zone cases are considered healthy.